UMEÅ UNIVERSITY MEDICAL DISSERTATIONS
New series No 915 • ISSN 0346-6612 • ISBN 91-7305-726-6
From Division of Psychiatry, Department of Clinical Sciences,
Umeå University, Sweden
and
Department of Psychiatry, Medical Faculty,
León University, Nicaragua
Mental health in Nicaragua
with special reference to psychological trauma
and suicidal behaviour
José Trinidad Caldera Aburto
Umeå 2004
© Copyright: José Trinidad Caldera Aburto
ISBN 91-7305-726-6
Printed by Print & Media, Umeå 2004:2000312
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Original papers
The thesis is based on the following papers:
I. Penayo U, Caldera T and Jacobsson L. Prevalence of mental
disorders among adults in Subtiava, León, Nicaragua
(Original paper in Spanish) Boletin de la Oficina Sanitaria
Panamericana 1992: 113:137-148.
II. Caldera T, Palma L, Penayo U and Kullgren G. Psychological impact of the hurricane Mitch in Nicaragua in a
one-year perspective. Social Psychiatry and Psychiatric Epidemiology 2001; 36:108-114.
III. Caldera T, Herrera A, Salander Renberg E and Kullgren G.
Parasuicide in a low-income country: results from threeyear hospital surveillance in Nicaragua. Scandinavian
Journal of Public Health 2004. In press.
IV. Caldera T, Herrera A, Kullgren G and Salander Renberg E.
Suicide intent among suicide attempters in Nicaragua:
surveillance and follow-up study. 2004. Submitted manuscript.
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Abstract
This thesis explores mental health problems relating to war and natural disaster
and suicidal behaviour in the Nicaraguan population. The more specific aims of
the study were to assess the prevalence and sociodemographic correlates of mental
disorder in a community-based study during time of war (Paper I), to assess the
mental health impact of Hurricane Mitch in 1998 (Paper II), to assess the
incidence of hospitalized parasuicide cases and groups at risk (Paper III), and to
examine suicide intent among attempters relating to gender, suicide method and
sociodemographic factors and identify predictors for repetition of an attempt
(Paper IV).
Method: Based on 4453 family food ration books for families living in an urban
area of León, Subtiava, 219 families including 746 adults were selected through a
systematic sampling procedure. The study was conducted in 1987 during the war.
We were able to reach 584 adults for interview according to the Present State
Examination for ICD-9 diagnoses and Self-Report Questionnaire (Paper I). In
Paper II, 496 adult primary health care attendees were interviewed six months
after Hurricane Mitch according to the Harvard Trauma Questionnaire and were
diagnosed for post-traumatic stress disorder (PTSD) according to DSM-IV. In
Papers III and IV, all cases from León city admitted to HEODRA Hospital for a
suicide attempt over a three-year period (n=233) were interviewed regarding
sociodemographic factors and method, time and place of the suicide attempt. A
subgroup of 204 cases was interviewed using the Suicide Intent Scale (SIS). Out of
those 106 cases were followed-up regarding repetition of attempt or completed
suicide after a mean period of 1172 days.
Results: In the Paper I study, the one-month prevalence of any mental disorder
was 28.8% for men and 30.8% for women. Among men, alcoholism was the most
common diagnosis, whereas neurosis, crisis reaction and depression were
dominant among women. Alcoholism was scored as the second most severe
disorder after psychosis in terms of functional level. In the Mitch study six months
after the hurricane, traumatic events were common and 39% reported death or
serious injury of a close relative as a result of the hurricane. The prevalence of
PTSD ranged from 4.5% in the least damaged area to 9.0% in the worst damaged
area. At the prolonged follow-up six months later, half of the cases still retained
their diagnosis. Trauma-related symptoms were common and death of a relative,
destroyed house, female sex, illiteracy and previous mental health problems were
associated with a higher level of symptoms. Suicidal ideation was reported among
8.5% and was significantly associated with previous mental health problems and
illiteracy. The studies regarding hospitalized parasuicides showed the highest rate
among girls aged 15–19 years (302 attempts per 100 000 inhabitants and year).
After drug intoxication, pesticide was the second most common method and most
often used by men (23%). Half of the women had recent contact with health care
services before attempting suicide. There were significant peaks regarding time of
attempt in terms of seasonal and diurnal distribution. Overall scores regarding
seriousness of the intent (SIS) were equal between the sexes, but the pattern of SIS
items showed significant gender differences in terms of relation to background
factors and method used. For women, having a child was one factor associated
with higher seriousness. Factor analysis of SIS items revealed a four-factor
solution, explaining 59% of the variance. Risk for fatal repetition was 3.2% after
three years and for non-fatal repetition 4.8%. During follow-up, three men (11%)
had completed suicide but no women. We failed to identify any predictors for
repetition from background factors or SIS.
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Conclusion: The studies have identified different groups at risk for mental health
problems relating to war and disasters. Parasuicide rates equalled those from
European countries. Whereas young girls dominated, attempts among men were
more severe in terms of the methods used and completed suicide at follow-up. SIS
seemed to give a meaningful pattern among women but not for men. In our
study, seriousness of attempt in terms of method or suicide intent did not predict
repetition. Overall non-fatal repetition rate was very low as compared to other
studies.
Key words: mental disorder, prevalence, post-traumatic stress, parasuicide
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Resumen
Esta tesis explora los problemas de salud mental relacionados con la guerra, el
desastre natural y el comportamiento suicida en una población de Nicaragua. Los
objetivos específicos de este estudio fueron evaluar la prevalencia y los factores
sociodemográficos asociados a trastornos mentales en un estudio basado en la
comunidad durante un periodo de guerra (Artículo I), evaluar el impacto en la
salud mental del huracán Mitch en 1998 (Artículo II), evaluar la incidencia de
casos de para-suicidios hospitalizados y grupos de riesgo (Artículo III), y examinar
los intentos de suicidio con relación al sexo, método de suicidio y factores
sociodemográficos así como identificar aquellos factores que predicen la repetición
de un intento (Artículo IV).
Método: Mediante un procedimiento de muestreo sistemático basado en 4.453
libros de racionamiento alimentario familiares utilizados durante la guerra, se
seleccionaron 746 adultos pertenecientes a 219 familias en un área urbano,
Subtiava, de León. Quinientos ochenta y cuatro adultos se entrevistaron con el
cuestionario “Present State Examination” para diagnósticos de la CIE-9 y el “SelfReporting Questionnaire” (Artículo I). En el Artículo II, 496 adultos que
acudieron a un centro de atención primaria seis meses después del huracán Mitch,
se entrevistaron mediante el cuestionario “Harvard Trauma”, siendo diagnosticados de trastornos de estrés post-traumático (TSPT) según el DSM-IV. En los
Artículos III y IV, se entrevistaron todos los casos de intento de suicidio que se
admitieron en el hospital HEODRA de la ciudad de León durante un periodo de
tres años (n=233) con relación a los factores sociodemográficos y el método,
periodo y lugar del intento de suicidio. Se entrevistó también un subgrupo de 106
casos utilizando la “Suicide Intent Scale” (SIS, Escala de Intento de Suicidio), a
quienes se les realizó un seguimiento durante un periodo medio de 1.172 días con
relación a la repetición del intento de suicidio o la consecución del mismo.
Resultados: En el Artículo I, la prevalencia de trastornos mentales en un mes fue
de 28,8% en los hombres y 30,8% en las mujeres. Entre los hombres, el
alcoholismo fue el diagnóstico más frecuente, mientras que la neurosis, la crisis
reactiva y la depresión fueron más comunes entre las mujeres. El alcoholismo fue
puntuado como el segundo trastorno más grave después de la psicosis en términos
del nivel funcional. En el estudio del Mitch, seis meses después del huracán, los
eventos traumáticos fueron habituales y el 39% informó de la muerte o de un
accidente grave de un pariente cercano como consecuencia del huracán. La
prevalencia de los TSPT varió entre un 4,5% en el área menos afectada y un 9,0%
en la más afectada. Seis meses después, la mitad de los casos todavía mantenían su
diagnóstico. Los síntomas relacionados con el trauma fueron comunes y la muerte
de un familiar, la destrucción de la vivienda, el ser mujer, el analfabetismo y el
padecer previamente problemas mentales estuvieron asociados con un mayor nivel
de síntomas. El 8,5% informaron de la ideación suicida y estuvo estadísticamente
asociada con el padecer previos problemas mentales y el analfabetismo. Los
estudios sobre los casos hospitalizados de para-suicidios mostraron la mayor tasa
entre mujeres entre 15-19 años de edad (302 intentos por 100.000 habitantes y
año). Después de la intoxicación por medicamentos, los pesticidas fueron el
segundo método más frecuente, principalmente utilizado por los hombres (23%).
La mitad de las mujeres había tenido un contacto reciente con los servicios de
salud antes de intentar cometer suicidio. Hubo picos importantes en cuanto al
periodo de intento en términos de estación y distribución horaria.
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Las puntuaciones totales según la “SIS” fueron iguales en ambos sexos, pero la
distribución de los puntos de la “SIS” mostró diferencias significativas por sexo
con relación a los antecedentes y métodos utilizados. En las mujeres, el tener un
hijo fue un factor asociado con una mayor severidad. El procedimiento de “factor
analysis”de los puntos de la “SIS” resultó en cuatro factores, explicando el 59% de
la varianza. Después de tres años de seguimiento, tres hombres (11%), pero
ninguna mujer, se habían suicidado. La tasa de repetición de un nuevo intento fue
de 0,03 intentos por 1000 personas-años entre los hombres y de 0,05 entre las
mujeres. No se pudo identificar ningún factor que predijera la repetición entre los
antecedentes o la “SIS”.
Conclusión: Los estudios han identificado diferentes grupos de riesgo de problemas mentales con relación a la guerra y los desastres naturales. Las tasas de
para-suicidios fueron equivalentes a las de los países europeos. Tras el periodo de
seguimiento, mientras los intentos fueron más frecuentes entre las mujeres jóvenes,
entre los hombres fueron más graves con relación a los métodos utilizados y el
desenlace final. La “SIS” pareció mostrar una significativa distribución entre las
mujeres pero no entre los hombres. La severidad del intento con relación al
método utilizado y la puntuación de la “SIS” no predijeron la repetición.
Palabras claves: trastorno mental, prevalencia, estrés post-traumático, parasuicidio
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Contents
Original papers .......................................................... III
Abstract...................................................................... IV
Resumen .................................................................... VI
Contents .................................................................... IX
Introduction ................................................................ 1
Description and history of the country ................................ 1
Mental health services ......................................................... 4
Natural disasters – a Nicaraguan plague .............................. 5
Background and aims................................................... 7
Method...................................................................... 10
Ethical considerations........................................................ 12
Results ....................................................................... 13
Conclusions ............................................................... 15
Implications – some examples ........................................... 17
Acknowledgement...................................................... 19
Funding ............................................................................ 20
References.................................................................. 21
Appendix
Paper I - IV
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Mental health in Nicaragua
Introduction
Description and history of the country
Nicaragua “land of lakes and volcanoes” is located on the Central
American Isthmus, on the “ring of fire” around the Pacific Ocean
known for centuries for its volcanic activity. In the west of Nicaragua
the volcanic mountains the “Maribios” face the Pacific Ocean, and in
the east Nicaragua reaches the hurricane area of the Caribbean Sea.
Nicaragua covers 130 682 km² and has 4 139 486 inhabitants (1995
census): 52% are women and 45.4% are under 15 years of age; only
2.8% are older than 65 years. The country is one of the poorest in
Central and Latin America. The Nicaraguan population has been
growing at 3.1% per annum in recent years, which is one of the
highest rates in Latin America.
Sixty-two percent of the population lives in the Pacific area (13% of
the land area). There is a mix of ethnic groups, with 76% “Mestizos”,
11% Afro-Caribbean, 10% Caucasian and 3% Indian. Historically,
the Nicaraguan isthmus was a transit corridor for northern and
southern Indian cultures. Nicaraguan culture was originally influenced
by three different Indian cultures: Maya, Aztec and Inca. These
cultures dominated the region for several centuries and the impact of
Spanish culture represents in this perspective a recent occurrence.
Indian culture is still markedly influential in Nicaragua.
Spanish influence began in 1502 when, on his fourth voyage,
Columbus reached the Nicaraguan coast, and a long period of colonization followed. The Nicaraguan people have suffered many conflicts
since the Spanish conquest. After the declaration of independence
from Spain on 15 September 1821 and the separation from Mexico,
Nicaragua faced a chaotic political situation that ended with the
formation of two political parties – representing the conservative
landowners of the city of Granada and the liberal traders of the city of
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Mental health in Nicaragua
Leon respectively. The parties were in constant and devastating
conflict until mercenaries from the United States – under the
leadership of William Walker – invaded in 1855. The two political
parties managed to cooperate and one year later Walker was forced out
of Nicaragua.
0
10
20
30 kms
Honduras
Lake
Managua
Los Maribos mountain range
Managua
Casita
León
Chinandega
Posoltega
Quezalguaque
La Paz Centro
El Tamarindo
Poneloya
Pacific Ocean
Map of León and the study area.
In 1926, a new invasion from the United States resulted in a war of
liberation, which was successfully led by the legendary hero Augusto
Cesar Sandino, who was murdered by the dictator and US-supported
Somoza a year later. The Somoza family ruled Nicaragua until 19 July
1979, when the Frente Sandinista de Liberación Nacional (FSLN) came
to power after a revolutionary war.
The FSLN remained in power from 1979 to 1990, during which the
Nicaraguan population was to experience hope as well as despair.
Huge economic and human resources were invested to increase
literacy and improve public health in vaccination programmes and
investment in health care services. However, Nicaragua was soon to reenter a state of war when the US government refused to accept the
FSLN government. The “Contras”, supported by US agencies, created
a situation of full-scale civil war. During the Sandinista period,
100 000 people were killed and over 350 000 left the country to
escape from war and chaos. Nicaragua entered a period of wartime
economy, with food rationing and government control of all economic
activities. Thousands of people were forced to move close to the
borders, men were enlisted in the army and families were uprooted.
Short-term partnerships often replaced traditional marriages, divorces
became more common, and mothers were left to take sole
responsibility for their children.
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Mental health in Nicaragua
The prolonged war and its
devastating consequences for NICARAGUA
Area: 130.668 Km2
the country’s economy forced Capital: Managua
the FSLN government to orga- People: 5.1 million
nize democratic elections in Population under 18 years of age: 53 %
Annual population growth rate: 2.7 %
1990. The Nicaraguan people, Per capita gross national product: $453
exhausted by the constant cir- One of every four house holds is headed by
cumstances of war, voted for a a woman
Poverty affects 2.3 million persons
new government that could be Languages: Spanish, English Creole, Miskito
installed without further con- Religion: Catholic 95%, Others 5%
flict. Doña Violeta Barrios de
Chamorro became the new president and Nicaragua experienced a
new dramatic shift, this time from a strictly state-controlled economy
to a liberal market economy.
The 1990-96 government faced a number of post-war problems, such
as hyperinflation, rapidly increasing unemployment and disintegration
of the country’s infrastructure. Cotton production, the dominant
agricultural crop, had to be abandoned due to severe soil erosion; the
world market price for sugar dropped and tobacco production moved
out of the country. From 1997 to 2002, Arnoldo Aleman served as
president. Accused of extreme corruption, he was forced to resign in
2002.
The effect of Nicaragua’s changing political system on health
(Hamlin Zuniga M, 1998).
- 1979
Somoza
Conservative
1979 - 89
Sandinistas
Revolutionary
1990 Chamorro / Aleman / Bolaños
Market oriented
Neoliberal
Curative aspects
Doctors and hospitals for urban
rich
Too costly and inaccessible for the
poor majority
People based rural and community
health posts
Free services accessible to almost all
Many health posts closed down
Privatisation and cost recovery put
services out of reach
Excellent preventive campaigns
vaccinations,
clean-up,
popular education in health
Preventive work desired
but unable to mobilize people
NGOs active in preventive work
Rapid health improvement and fall in
child mortality
IMR 65 / 1000
Stagnation and reversals in health and
child mortality
IMR 41 / 1000
Preventive services
Did very little preventive work
Impact on health
Poor health and very high child
mortality
IMR 129-140 / 1000
Special events with impact on health situation
Natural disasters:
earthquake
Adult illiteracy 52%
Natural disasters:
floods, volcano eruptions,
earthquakes
The contra-revolutionary war and US
embargo created scarcity, 40 000
deaths,
10 000 disabled and eroded the
benefits of the revolution
Adult illiteracy 12%
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Natural disasters:
hurricane Mitch (1999), volcano eruptions
Adult illiteracy 35%
Mental health in Nicaragua
The new government under the leadership of Enrique Bolaños has
initiated extensive and tough economic reforms to restore the
economy. The gap between rich and poor has widened, the health care
system has deteriorated and infant mortality has once more increased.
There are good reasons to assume that the rapid and pervasive social
changes that took place when the country moved from a dictatorship
under Somoza to Sandinista socialism in 1979 and further to a free
market economy in 1990 have had a significant impact on the
Nicaraguan population, not least in terms of mental health.
Mental health services
The history of psychiatry in Nicaragua began in 1910 when the
Asylum for the Alienated was built – a combination of hospital and
prison. Under the Sandinista government, efforts were made to
respond to the needs of patients in the hospital. Basic custody was
replaced by treatment, and decent clothes and meals were provided for
the patients. An occupational therapy unit was established and a
limited outpatient service was made available. With the departure of
the Sandinistas, the ambition to reform the psychiatric hospital was
abandoned. Today in 2004, there are no adequate means of treatment
and resources are too scarce to satisfy the basic everyday needs of the
patients.
While the mental hospital has continued to function as a remnant of
asylum psychiatry, it has been possible to develop modern community
mental health services, at least in some parts of Nicaragua. In the
1960s, Nicaraguan psychiatrists who had trained in Mexico and Spain
returned to Nicaragua followed by a group of psychiatrists trained in
Costa Rica the following decade. They managed to establish
psychiatry as a respected branch of medicine and part of the
curriculum in medical education at the universities. In the early
1980s, Nicaragua also established a national residency programme in
psychiatry.
Influenced by the returning
Nicaraguan psychiatrists, community mental health services
(Centro de Atención Psicosocial
or CAPS) were established, first
in Managua in 1982. In 1987
the first unit outside the capital
was opened in León, followed
by units in Chinandega and
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Mental health in Nicaragua
Grenada. Influenced and supported by psychiatrists and psychologists
from Mexico and Sweden, CAPS León developed a new model for
mental health services where group activities for patients and relatives
play an important role. Positive experiences have been reported from
this way of working, from professionals, patients and relatives.
Working with groups seems to be a cost-effective alternative for poor
countries where resources for mental health services are scarce
(Caldera, et al., 1995).
Natural disasters – a Nicaraguan plague
Disruption of the crater lake at Casita volcano and floods during Hurricane Mitch.
Natural disasters are frequent in human history. The Bible refers to
the Deluge, where it rained for 40 days and 40 nights. The Popool
Vooh, the sacred book of the Maya, talks about disasters as long
periods of rain. In our time, East and South Asia and the Pacific have
the highest rate of natural disasters, with more than 600 major natural
disasters over a 40-year period.
Table 1. Significant natural disasters in the history of Nicaragua.
Year
Area
Type of disaster
1610
Old León
Earthquake, volcanic eruption
Momtombo
1931
Managua
Earthquake
1964
Managua
Earthquake
1970
León
Volcanic eruption Cerro Negro
1972
Managua
Earthquake
1973
Atlantic and Pacific coast
Hurricane Fifi
1988
Atlantic and Pacific coast
Hurricane Johanna
1992
León
Volcanic eruption Cerro Negro
1992
Pacific coast
Tidal waves
1996
León
Volcanic eruption Cerro Negro
1998
Atlantic coast and the North
Hurricane Mitch
2000
Masaya
Earthquake
2004
Central Nicaragua
Landslide
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Mental health in Nicaragua
However, the number of deaths from disasters relative to the number
of inhabitants was the second highest in the world in Latin America
and the Caribbean (Glickman, et al., 1994).
Nicaragua has had its share of disasters (Table 1). In 1988, Hurricane
Johanna swept across the country from the Caribbean to Pacific:
destruction of property and infrastructure was widespread, though
human losses were small. A tidal wave in September 1992 affected
thousands of kilometres of the Pacific coast, with three hundred
people dead and thousands injured. More recently, Hurricane Mitch
struck western and northern Nicaragua, resulting in 2000 deaths and
10 000 people losing their homes. The material destruction was
devastating with 3000 kilometres of roads and more than 100 bridges
destroyed.
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Mental health in Nicaragua
Background and aims
The prevalence of mental disorders in low-income countries has been
the subject of extensive research in the last decade, very much
stimulated by WHO reports such as World Mental Health: Problems
and Priorities in Low-income Countries (Desjarlais, et al., 1995). The
WHO report on the burden of mental disorder made it clear that
mental disorders also represent a neglected major public health
problem in low-income countries (WHO, 2001).
In Nicaragua little is known about the prevalence and distribution of
mental illnesses in the population. In a previous study, we explored
community attitudes and awareness of mental disorders among key
informants (Penayo, et al., 1988). In another study, we showed that
mental health problems were frequent among primary health care
patients, but often neglected by physicians (Penayo, et al., 1990). In
1986, a survey was conducted among patients at the two CAPS units
in Managua and a number of selected primary health care settings
throughout Nicaragua to assess the treated prevalence of mental
disorders (Kraudy, et al., 1987). The prevalence figures were limited to
patients undergoing treatment and did not examine mental health
problems in the population. The study in the present thesis conducted
in Subtiava in the late 1980s represents the first and as yet only
community-based study carried out in the country.
Suicide is one of the leading causes of un-natural death in the world,
with an estimated one million people committing suicide every year
worldwide. The number exceeds those killed in war. Suicide depends
on the interaction of many factors, including neurobiological, genetic,
psychosocial, cultural, and environmental risk and protective factors.
Suicide rates differ between cultures and countries, and risk factors
differ between settings and fluctuate over the life span. Suicide is not
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Mental health in Nicaragua
only a problem of the highly industrialized societies. In fact, certain
developing countries are among those with the highest suicide rates in
the world (WHO, 2001). In Nicaragua, there has been a more then
three fold increase in suicide rate from 1990 to 2002 as illustrated in
Figure 1.
Suicide per year
400
350
300
Women
250
200
150
100
50
Men
0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
Figure 1.Frequency of suicides in Nicaragua 1990-2002.
Individuals who have been admitted to hospital as a result of a suicide
attempt constitute a risk group for a future completed suicide
(Iribarren, et al., 2000 R; Suominen, et al., 2004). Further assessment
to identify individuals at high risk among those admitted to hospital
after a suicide attempt might help in prioritizing those most in need of
intervention.
No psychological tests, clinical assessments or biological markers have
so far been proven to be sufficiently sensitive and specific to accurately
predict suicide (Goldstein, et al., 1991). It seems unlikely that a
perfect instrument for prediction will ever be constructed, but a
structured approach using an instrument still has advantages. It guides
the health care professional in addressing crucial risk factors and documents his or her assessment. One of the most widely used measures,
the Suicide Intent Scale or SIS (Beck, et al., 1974), has performed
reasonably well in some studies. In a 20-year follow-up study, Brown
and co-workers (2000) showed that high scorers on SIS were about
6.5 times more likely to complete suicide than low scorers. Other
studies with shorter follow-up periods have, however, failed to show
any association between SIS scores and repetition (Beck, et al., 1989;
Hawton, et al., 2003).
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Mental health in Nicaragua
Disasters contribute greatly
to mental health problems:
in a meta-analysis of 39
studies, it was estimated
that disasters increased the
rate of psychopathology by
approximately 17% (Rubonis and Bickman, 1991). In
poor countries, few victims
are likely to receive support
or treatment for mental health problems following a disaster (Lima, et
al., 1991). Even though overall psychopathology is likely to increase,
post-traumatic stress disorder PTSD and symptoms associated with
PTSD are of particular interest since they have a clear causal link with
the disastrous event.
The overall aims of the thesis were to study mental illness with special
reference to PTSD and suicidal behaviour in a poor country that has
suffered both war and natural disasters.
In the Subtiava study, the aims were to estimate the prevalence of
mental disorders in a typical Nicaraguan urban setting during war and
identify groups at risk for mental health problems. The study after the
hurricane Mitch aimed at assessing its impact on mental health six
months after the disaster and at identifying exposure characteristics
and individual background factors related to long-standing mental
health problems after a disaster.
In the hospital surveillance of suicide attempters we wanted to assess
the incidence of hospital admitted parasuicides, to explore the context
of the parasuicides and to identify socio-demographic groups at risk.
Further aims were to examine levels of suicide intent as measured by
Suicide Intent Scale (SIS) as related to socio-demographic characteristics, in particular gender, and methods used for suicide attempt. In
addition, we aimed at examining the predictive value of SIS for fatal
and non-fatal repetition of a suicidal act.
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Mental health in Nicaragua
Method
Paper I “Subtiava”: The
study was conducted in Subtiava, a district of the city of
León in Nicaragua during a
period of war in 1987.
During that period every
family had a food ration
book. All ration books had a
corresponding card filed with
the authorities. From the
4453 family cards for all the families living in Subtiava, ten families
were randomly selected. From these index families, ten families living
to the left and nine families to the right of each index family were
selected, giving 219 families with 1184 individuals. In the selected
families in total there were 746 adults aged 15 years or over according
to the family cards. All families were visited three times to improve the
response rate: we were able to reach 584 individual adults for inclusion
in the study, 201 men and 383 women. A multiple imputation
procedure was performed to correct for non-responses.
Mental distress was assessed by means of the Self-Report
Questionnaire (SRQ), a self-report instrument for mental distress
developed by the WHO (Mari, et al., 1986). Psychiatric diagnoses
were made according to the Present State Examination (PSE), a semistructured interview for ICD-9 diagnoses of mental disorders
(Sartorious and Harding, 1983)
Paper II “Hurricane Mitch”:
In October 1998 Hurricane
Mitch struck Nicaragua, resulting in more than 2000
deaths. For our study we
chose four communities: two
communities severely struck
by the hurricane were compared with two communities
that were less devastated. In
the study we included all
consecutive patients aged 15–80 years visiting primary health care
centres in all four communities between 19 and 28 April 1999, i.e.
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Mental health in Nicaragua
around six months after the disaster. In total 516 individuals were
asked to participate, with 496 agreeing to be included.
All patients were interviewed according to the Harvard Trauma
Questionnaire (HTQ), an instrument developed by Mollica and coworkers (1992) to estimate the type and degree of trauma, posttraumatic stress symptoms and help-seeking pattern. The patients were
diagnosed according to the Diagnostic and Statistical Manual of
Mental Disorders, fourth edition by means of a clinical interview.
Paper III “Hospital surveillance” and Paper IV “Suicide
intent”: All consecutive cases
admitted for a suicide attempt
to HEODRA Hospital in
León from 1 March 1999 to
the end of February 2002 were
invited to participate in the
study (N=326). After exclusion
of 17 cases who eventually died as a result of the suicide attempt and
76 cases living outside the study area, 233 parasuicide cases were
included in the analyses. Patients who did not wish to be interviewed
(12%) gave consent to include data from clinical records for the study.
For the interviews regarding suicide intent, 204 cases admitted during
the three-year surveillance were available for assessment.
In a follow-up two to five years later, 98 individuals out of 204 cases
who had been interviewed according to SIS could not be traced,
leaving 106 cases for follow-up. After identifying completed suicides
through registers (n=3), 103 cases were re-interviewed and asked
whether they had re-attempted suicide during follow-up. None of the
cases was identified in hospital registers for re-admission after a suicide
attempt and repetition of attempt was therefore based on self-report.
We used research protocols and instruments developed within the
framework of the WHO/EURO Multicenter Study on Parasuicide,
which has been used in several European studies (Platt, et al., 1992;
Schmidtke, et al., 1996).
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Mental health in Nicaragua
Ethical considerations
When the Subtiava study was launched, there was no formal procedure at León University for ethical clearance and MINSA, which is
the authority in charge of health care, was responsible for decisions
regarding research. Our study was approved by MINSA. Health care
workers performed the interviews and assessments after informed
consent of the interviewees. If a mental health problem was identified,
treatment was offered either at the primary health care centre in
Subtiava or at CAPS León.
The Hurricane Mitch study went through a formal ethical clearance
procedure, with approval granted by the Ethical Research Committee
at the Medical Faculty of León University. Informed consent was
obtained and treatment offered when needed.
The surveillance study was also approved by the Ethical Research
Committee in León. All patients under 15 years of age were
interviewed after consent from an adult relative. A few patients did not
wish to be interviewed but gave permission for data to be extracted
from records and used in the study. We informed patients that there
might be future contact by the researchers for follow-up purposes. At
follow-up, death registers were first screened to identify completed
suicides; in the next step, individuals were contacted and asked about
repeat attempts. A few individuals who were found in need of
treatment were offered this at CAPS.
In summary, we believe that the studies were carried out according to
good ethical practice.
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Mental health in Nicaragua
Results
In the “Subtiava” study the overall one-month prevalence of any
mental disorder was 28.8%, for men 30.8% and for women 26.3%.
Mental disorders were more common among illiterates. For specific
disorders according to ICD-9 the one-month prevalence for neurosis
was 6.9% (95% CI= 5.2-9.8%), depression 5.5% (95% CI = 2.68.1%), reactive crisis 4.3% (95% CI = 2.6-6.5%), alcoholism 6.7%
(95% CI = 3.9-8.9), organic brain syndromes 4.0% (95% CI = 1.75.2%), psychosis 0.8% (95% CI = 0.2-1.6%), and other mental
disorders 0.6% (95% CI = 0.2-1.6%). Considering gender differences,
neurosis and depression were the most frequent disorders among
women whereas alcoholism was the main diagnosis among men, with
21 cases out of a total of 62 male cases compared to only 1 out of 101
female cases. According to the PSE gravity scale, psychosis was, as
expected, rated as the most dysfunctional disorder, alcoholism was
second followed by lower gravity scores for depression and neurosis.
For mental distress according to the Self-Report Questionnaire,
significantly more women scored above the cut-off. On drug abuse
items in the SRQ men scored significantly higher than women, but
among all other ten items where there was a significant gender
difference, women scored higher. Suicidal ideation was confirmed in
15 out of 44 cases with neurosis, 16 out of 36 cases with depression
and 8 out of 34 cases with alcoholism.
In “Hurricane Mitch” study, overall, 39% of the individuals reported
the death or serious injury of a close relative and 72% had their house
partly or completely destroyed. The prevalence of post-traumatic stress
disorder ranged from 9.0% in the worst affected areas to 4.5% in the
less damaged areas. From a dimensional perspective, according to the
HTQ, PTSD symptoms six months after the disaster were significantly associated with the death of a relative (ȕ-coefficient 0.257,
p = 0.000), destroyed house (ȕ-coefficient 0.148, p = 0.001), female
sex (ȕ-coefficient 0.139, p = 0.001), previous mental health problems
(ȕ-coefficient 0.109, p = 0.009) and illiteracy (ȕ-coefficient 0.110, p =
0.009). Individuals with previous mental health problems were more
likely to seek any kind of help for mental health problems after
Hurricane Mitch, and individuals who were illiterate were less likely to
seek professional help than others. Altogether 8.5% reported that they
had thought of taking their lives. Those with previous mental health
problems were more likely to report suicidal ideas (OR=2.84;
95%CI=1.12-4.57) as were illiterate individuals (OR=2.84 95%CI=
1.12-4.37).
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Mental health in Nicaragua
In the “Hospital surveillance” study 233 cases were included, 68.8%
women and 31.2% men, giving a parasuicide rate of 66.3/100 000
inhabitants per year based on the population ten years of age and
older. For the age span 15 years and older, the parasuicide rate was
71.3/100 000 inhabitants per year. The highest parasuicide rate was
for women in the age group 15-19 years. In the age groups 10-14
years and 15-24 years, the male to female ratio was 1:9.5 and 1:2.7
respectively. The proportions were inverted for the age groups 25-34
years and 45-54 years, with male to female ratios of 1:0.9 and 1:0.8
respectively. The predominant method of attempted suicide was drug
intoxication followed by ingestion of pesticide, with no gender and
age differences for the method used. Almost 80% had had previous
contact with health facilities, most of them in the six months
preceding the attempt. Among females younger than 25 years, 45.7%
had had recent contact; among men older than 34 years, 80.0% had
had such a contact. We found two seasonal peaks, May-June and
September-October. Parasuicides occurred most frequently between
1100 to 1300 hours and 1900 to 2100 hours.
In the “Suicide intent” study there were no significant differences
between the mean total SIS sum score for men (10.77 SD=5.48) and
women (10.72, SD=6.72). Among men the SIS sum score showed no
association with any sociodemographic variable. Among women there
was an association with higher age and higher SIS scores.
Furthermore, women who were separated had higher scores than
single women, and women who had children had significantly higher
scores than women without children. For suicide method, there were
differences in SIS scores as related to method used only among women
where those who used pesticides had higher scores than others.
To further analyse whether the association among women between
high SIS scores and having children, being separated or using
pesticides in a suicide attempt could be explained by a greater age of
women in these groups, multiple regression analyses were performed.
Having a child remained significantly associated with higher SIS scores
also after controlling for age (beta coefficient=.247, p=.012). Using
pesticides also remained significantly associated with high SIS scores
(beta coefficient=.234, p=.004). However, being separated did not
remain significant among women after controlling for age.
Women showed higher scores on Timing and Precaution against
discovery, and lower scores on Purpose to die.
A factor analysis resulted in a four-factor model explaining 59.2% of
the total variance. The first factor seemed to comprise items related to
preparatory activities and was labelled Preparations. The second factor
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Mental health in Nicaragua
was mixed but included elements of Wish to die. The third factor was
interpreted to refer to Expectations, and the fourth factor included
items that might be linked to Decisiveness.
The total follow-up period was 124 197 person days, ranging from 18
to 1918 days with a mean of 1171.7 days. Three persons - all men had committed suicide during follow-up. Based on person days of
follow-up, there were substantial gender differences with 0.1 completed suicides per 1000 person days and 0.03 attempts per 1000
person days among men compared to no completed suicides among
women and 0.05 attempts per 1000 person days.
Since there were so few cases of both repeat attempts and completed
suicides, the analyses had to be confined to any type of repetition for
both men and women combined. Interpretation of the analyses
regarding predictive power must, of course, be with extreme caution
due to the small numbers. Since completed suicide occurred only
among men during follow-up, male sex is obviously in itself a risk
factor for fatal repetition.
A Cox regression analysis was performed with completed or attempted
suicide during follow-up as the dependent variable, and having a child,
male sex, age and use of pesticides and drugs (index method) as
respective co-variates. None of the co-variates emerged as significantly
associated with repetition.
We also performed analyses according to Receiver Operating Characteristics (ROC curves) to examine the power of the SIS sum score,
subscale scores and factor scores to predict repetition. Neither scores
were associated with repetition in our sample.
Conclusions
In the Subtiava study alcoholism was the major mental health problem
among men, representing half the cases diagnosed with a mental
disorder. It was also striking that alcoholism was rated as very severe in
terms of dysfunction and almost as severe as psychosis. Among women
neurosis was six times more common, and one tenth of the women
with any diagnosis suffered from a crisis reaction. The overall
prevalence figures for women were high and there were indications
that overall women suffered more and that conditions related to the
war situation, such as a family member enrolled in the army, contributed to mental health problems particularly among women.
The study after Hurricane Mitch showed that, six months after the
hurricane, one in ten primary health care attendees suffered from a
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Mental health in Nicaragua
post-traumatic stress disorder and chronicity was high, with half still
fulfilling the criteria after one year. It seemed that avoidance
symptoms increased the risk of long-term illness. The overall level of
complaint regarding PTSD symptoms was high, in particular among
women. In planning for intervention after disasters, those who are
illiterate might need special attention since they seemed to get less
support from non-professionals in the network. Those with previous
mental health problems were more likely to have PTSD-related
problems and might need extra attention. Furthermore, the findings
suggest that suicide ideation should be targeted in intervention after
disasters, in particular among those with previous mental health
problems.
In the hospital surveillance study, parasuicide emerged as a significant
health problem, in particular among young women, with the
parasuicide rate among girls aged 15-19 the highest. In general, these
figures are in accordance with those from high-income countries, and
the low rate of parasuicides among men is more striking when
compared to the Western world as a whole.
Pesticides are easy to buy anywhere in León.
It must be emphasized that León is not representative of Nicaragua as
a whole. León is a university city with relatively decent living
conditions for most people compared to rural areas. It is a matter of
concern that the single most frequent method was ingestion of pesticide, a highly toxic substance. Almost one in four of men used
pesticides as a parasuicide method. In part as a result of our study,
measures to make pesticides less easily available in shops and markets
have already been initiated.
The follow-up study, based on those interviewed according to the SIS,
showed many marked gender differences. Men used more lifethreatening methods for their attempt and during follow-up only men
completed suicide, while self-reported suicide attempts were more
common among women, but still at a low rate in international
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Mental health in Nicaragua
comparison. For women a serious intent was reported among older
women and those who had children, regardless of age. We found it
difficult to identify any meaningful pattern of the SIS scale regarding
seriousness among men. Overall, the findings gave supported previously reported conclusions for cross-cultural validity of the Suicide
Intent Scale.
Our sample size for follow-up was small and the findings must be
interpreted cautiously. In the follow-up 11% of the men completed
suicide, which is a comparatively high figure, but only 4% committed
a new attempt according to the self-report. Among women 5% reattempted suicide. Figures on re-attempts were based on self-report
and did not include any re-admission to hospital, as far as we could
judge from hospital registers. Thus, repetition of parasuicide must be
considered surprisingly low. There are reasons to believe that the
research interview made directly after their attempt, followed by
referral for treatment when needed, might have contributed to low
rates of repetition.
Completed suicides occurred only among men and were not
uncommon. However, neither background factors nor the SIS seemed
to be able to predict these suicides. Among those men who used
pesticides at the index attempt, there were no suicides during followup. Even though SIS scores indicated a meaningful pattern among
women, we could not establish any association with seriousness
according to SIS and a repeated attempt. We realize that small sample
size and low base rates of repetition might have contributed to the
negative findings, but the lack of predictive value with SIS is in
accordance with some previous studies with similar length of followup periods.
Overall, our concluding interpretation is that SIS seems to be useful in
women in assessing the seriousness of a suicide attempt but is probably
less so in men. Furthermore, we believe that our findings show that
seriousness of intent is of limited value in predicting repetition of
suicidal behaviour which must be based on a combined assessment
using additional clinical measures.
Implications – some examples
One overall incentive for the work behind this thesis was that results
were to be disseminated back to the community. In several areas, this
goal has been achieved.
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Mental health in Nicaragua
The prevalence study in Subtiava was the first community based study
on mental disorders in Nicaragua. The results were used in the
National Mental Health Plan 1992 as a basis for discussing needs of
mental health services.
In the study of psychological consequences after hurricane Mitch, field
work was carried out at the primary health care centres in the areas
most severely struck by the hurricane. The interviewers sent out to the
centres were psychologists and professionals from the mental health
outpatient unit CAPS. The field work gave several occasions for the
mental health team to meet with PHC staff, report their experiences
and increase knowledge in PHC regarding psychological reactions
likely to occur after a disaster like this one. Lessons to learn were
among other things which groups might be at particular risk for longterm consequences and that somatic presentation might be common
after psychological trauma. The most important contribution was
perhaps the collaboration that grew out from the field work period
between the PHC-centres and the mental health unit.
The hospital surveillance of suicide attempts continued for three years
during which every hospital admitted case was interviewed, carefully
recorded and referred for treatment when needed. The study had a
notable effect in the community in several ways. Firstly, the
surveillance protocol and procedure were adopted in larger scale and
incorporated in a national surveillance program, headed by Center for
Disease Control in Atlanta, for emergency cases at general hospitals.
Secondly, based on our findings that pesticides were fairly commonly
used in suicide attempts, the community was alerted to take an
initiative which has made pesticides less available at the market and
shops. Thirdly, our research team managed to create an action group
in León with participation from leaders in the health care authorities
(MINSA), León University, CDC-Atlanta, non-governmental organisations and others. A pamphlet “Programa por la vida” (Appendix) has
been widely distributed with information on suicidal behaviour; how
to detect a person at risk, where to get more information and where to
get help for someone with suicidal ideation.
Overall, we believe that the most important impact from these studies
is that mental health problems have been placed on the agenda on
several community levels contributing to increased awareness and destigmatisation of people with mental health problems.
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Mental health in Nicaragua
Acknowledgement
When I did my first visit to Sweden, supported by the Swedish Institute, I
never imagined how much it could influence my life. Today, I achieve this
thesis as a result of a collaborative project between the Department of mental health of HEODRA, The Ministry of Health, SILAIS, León, Nicaragua
and the Department of Psychiatry, WHO Collaborative Center, University
of Umeå, Sweden. I would like to express my gratitude to all those involved
in the project in both countries and also to those who participated in the
research.
In particular I would like to mention the following persons:
Lars Jacobsson, who was very enthusiastic to initiate the research project,
and who has became an example to me as an excellent person and professional, always concerned about countries in difficult situations, like
Ethiopia, Nicaragua, Bosnia, etc. My difficulties with the English language
in the beginning never discouraged him. Our relationship has always been
open and friendly.
Gunnar Kullgren, my friend, co-author and supervisor whose suggestions
to the courses I should take have been very important. I will never forget his
generosity and cordiality to receive me in his home. I would like to mention
his double position, sometimes hard, asking difficult questions and at the
same times encouraging me to continue. I would really like to keep my
relationship with him even after I have finalized my thesis.
Ellinor Salander Renberg became part of this project later on. She contributed to the development of the surveillance system which has produced
two important papers enabling us to compare our figures with others
around the world. Thanks for the time you have sacrificed in order support
me in my work.
Ulises Penayo (Argentine-Swedish-Nicaraguan), who I met when I was in
psychiatry training taught me about community diagnosis. He found the
way to initiate the research collaboration between León and Umeå. He is
for me in many ways the older brother I never had.
Andres Herrera Rodrígues, my friend and co-author in our research on
suicide for his support.
Kjerstin Dahlblom, I would like to thank her for her own particular qualities. She has shown me what a great human being she is. She has been
involved a lot in this project, helped me many times with email, transportation and with the most important step to arrange this text into a book.
Julio Rocha, friend and colleague, contributed in many invaluable ways to
the hospital surveillance study.
Margaretha Lindh and Doris Cedergren, division of psychiatry Umeå, were
helpful in so many ways; taking care of all practicalities during my stays in
Sweden and giving secretarial support.
The Swedish Institute supported the first contact with the Umeå
University leading to further support by the Swedish Agency for Research
Collaboration SAREC which has supported the project for eighteen years.
Other colleagues who have facilitated my research training are Dr. Ernesto
Medina Rector of National University of Nicaragua, León, and Dr. Rene
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Mental health in Nicaragua
Altamirano Dean of Faculty of Medicine and others principals of
HEODRA.
Finally I would like to mention to my wife Maria Lucrecia Palma Ruiz, my
children Juan Carlos and Lydia Maria Caldera Palma, who are my most
loyal companions, even in difficult times. I must mention Jose Trinidad
Caldera López my father, always present in my life. And Lydia Maria
Tudose, my mother. My eldest son Trinidad Bismarck who did not see my
thesis and Luis Alberto Caldera.
Funding
These studies were carried out as part of a collaborative research project
between Umeå University, Sweden, and León University, Nicaragua. They
were funded by the Sida Development Research Council, SAREC, Sweden.
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Mental health in Nicaragua
References
Beck AT, Kovac M and Weissman A. Assessment of suicidal intention: The scale
for suicide ideation. J Consult Clin Psychol 1979; 47:343-352.
Bille-Brahe U, Kerkhof A, De Leo D, Schmidtke A, Crepet P, Lonnqvist J,
Michel K, Salander-Renberg E, Stiles TC, Wasserman D and Egebo H. A
repetition-prediction study on European parasuicide population: Part II of the
Who/Euro Multicentre Study on Parasuicide in cooperation with the EC
concerted action on attempted suicide. Crisis 1996; 17:22-31.
Brown GK, Beck AT, Steer RA and Grisham JR. Risk factors for suicide in
psychiatric outpatients: A 20-year prospective study. J Consult Clin Psychol
2000; 68:371-377.
Caldera T, Kullgren G, Penayo U and Jacobsson. Is treatment in groups a useful
alternative for psychiatry in low-income countries? An evaluation of a psychiatric outpatient unit in Nicaragua. Acta Psychiatr Scand 1995; 92:386-391.
Desjarlais R, Eisenberg L and Good B. World mental health: Problems and
priorities in low-income countries. Oxford: Oxford University Press, 1995.
Glickman, et al. World disaster report. Norwell: Kluwer Academic Publishers,
1994.
Goldstein RB, Black DW, Nasrallah A and Winokur G. The prediction of
suicide. Sensitivity, specificity and predictive value of a multivariate model
applied to suicide among 1906 patients with affective disorders. Arch Gen
Psychiatry 199; 48:418-422.
Hamlin Zuniga M. Nicaragua: health in a global era. Contact 1998; 159:6-10.
Hjelmeland H, Stiles TC, Bille-Brahe U, Ostamo A, Salander Renberg E and
Wasserman D. Parasuicide: The value of suicidal intent and various motives as
predictors of future suicidal behaviour. Arch Suicide Res 1998; 4:209-225.
Iribarren C, Sidney S, Jacobs DR and Weisner C. Hospitalization for suicide
attempt and completed sucide: epidemiological features in a managed care
population. Social Psychiatry Psychiatr Epidemiol 2000; 35:288-296.
Kraudy E, Liberati B, Asioli F, Sarraceno B, Tognoni G. Organization of services
and pattern of psychiaric care in Nicaragua: result of a survey in 1986. Acta
Psychiatr Scand 1987; 76:545-551.
Lima BR, Pai S, Santacruz H and Lozano J. Psychiatric disorders among poor
victims following a major disaster : Armero, Colombia. J Nerv Ment Dis
1991; 179 :420-427.
Mari MM and Williams P. A validity study of a psychiatric screening
questionnaire (SRQ-20) in primary care in the city of São Paulo. Br J
Psychiatry 1986; 148:23-26.
Penayo U, Jacobsson L, Caldera T and Bermann G. Community attitudes and
awareness of mental disorders – a key informant study in two Nicaraguan
towns. Acta Psychiatr Scand 1988; 78:561-566.
Penayo U, Kullgren G and Caldera T. Mental Disorders among primary health
care patient in Nicaragua. Acta Psychiatr Scand 1990; 82:82-85.
- 21 -
Mental health in Nicaragua
Platt S, Bille-Brahe U, Kerkhof A, Schmidtke A, Bjerke T, Crepet P, De Leo D,
Haring C, Lonnqvist J, Michel K, Philippe A, Pommereau X, Querejeta I.
Salander-Renberg E, Temasváry B, Wasserman D and Sampaio Faria J.
Parasuicide in Europe: the WHO/EURO multicentre study on parasuicide. I.
Introduction and preliminary analysis for 1989. Acta Psychiatr Scand 1992;
85:97-104.
Rubonis AV and Bickman L. Psychological impairment in the wake of disaster:
the disaster-psychopathology relationship. Psychol Bull 1991; 109:384-399.
Sartorious W and Harding T. The WHO collaborative study on strategies for
extending mental health care. Am J Psychiatry 1983; 140:1470-1492.
Schmidtke A, Bille-Brahe U, De Leo D, Kerkhof A, Bjerke T, Crepet P, Haring
C, Hawton K, Lönnqvist J, Michel K, Pommereau X, Qurejeta I, Phillipe I,
Salander Renberg E, Temesváry B, Wasserman D, Fricke S, Weinacker B and
Sampaio Faria JG. Attempted suicide in Europe: rates, trends and sociodemographic characteristics of suicide attempters during the period 19891992. Results of the WHO/EURO Multicentre Study on Parasuicide. Acta
Psychiatr Scand 1996; 93:327-338.
Suominen K, Isometsa E, Suokas J, Haukka J, Achte K and Lonnqvist J.
Completed suicide after a suicide attempt: a 37-year follow-up study. Am J
Psychiatry 2004; 161:562-563.
WHO The world health report, 2001: Mental health new understanding, new
hope. Geneva: World Health Organization, 2001.
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